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Based on observation it could not be confirmed that the laundry chutes were protected in accordance with vertical opening protection requirements found in NFPA 101.

Findings include:

1. On 3/13/19 at 11:00 AM during a building tour it was observed that on the 5th floor the laundry chute door was not labeled with a fire resistance rating. Subsequent checks of laundry chute doors on other floors revealed that other laundry chute doors were also missing fire rating labels. Therefore, the fire rating of laundry chute doors could not be determined.

2. On 3/13/19 at 11:15 AM during the building tour of the 4th floor it was observed that the door knob on the laundry chute door was sticking open when turned clockwise, causing the potential for the door not to latch properly upon closing.

These findings were reviewed with the Manager of Plant Operations and Director of Facilities Management at the time of observations.

Based on observation the linen collection room serving the linen chute was not maintained to limit the passage of smoke.

Findings include:

On 3/13/19 at 11:30 AM during a building tour it was observed that the linen collection room was not enclosed in a smoke resistant enclosure. There were several holes in the concrete walls of the room.

This finding was reviewed with the Manager of Plant Operations and Director of Facilities Management at the time of observation.

Based on record review and interview the sprinkler system was not maintained in accordance with NFPA 25.

Findings include:

On 3/14/19, the sprinkler report dated 1/11/19 and titled "Report of Inspection RBM-Guardian Fire Protection, INC." was reviewed. The RBM inspector noted on this report that there are sprinkler heads over 50 years old in the facility. A recommendation was made on the report to replace or test the heads. At the time of record review the Manager of Plant Operations was asked if this had been done and indicated it had not been done.

NFPA 25 section 5.3.1.1.1 requires sprinklers which have been in service for 50 years to be replaced or a representative sample be tested.

This finding was reviewed with the Manager of Plant Operations and Director of Facilities Management at the time of record review.

Based on observation the smoke compartment walls on multiple floors were not maintained to provide the required ½ hour fire resistance rating and smoke resistance.

Findings include:

On 3/12/19 at 2:00 PM during a tour of the facility unsealed penetrations were observed above the ceiling in the smoke compartment wall, on the 2nd floor adjacent to room 2120 where cables passed through the wall. This same observation was made above the ceiling at the smoke compartment walls on the 6th floor on 3/13/19 at 10:15 AM, and at the smoke compartment walls on the 5th floor on 3/13/19 at 10:30 AM.

These findings were reviewed with the Manager of Plant Operations and Director of Facilities Management at the time of observation.

Based on record review and interview the facility failed to maintain and test 1 of 4 generators in accordance with NFPA 110.

Findings include:

On 3/14/19 the maintenance and testing logs were reviewed for the B-52 building generator.

1. Records were reviewed from present date back through the year of 2015, for compliance with the 36-month frequency testing requirements specified in NFPA 110 section 8.4.9. There were no records of the 36-month test having been performed on this generator.

2. Records were reviewed for the year of 2018, for compliance with the monthly load test requirements specified in NFPA 110 section 8.4.1. It was found that 7 of 12 months did not have record of a load test being performed. The months missing a load test included: February, March, April, May, July, November, and December of 2018.

3. Records were reviewed for the year of 2018, for compliance with the weekly inspection requirements specified in NFPA 110 section 8.4.1. It was found that 3 of 12 months were missing some weekly inspections. The months missing weekly inspections included: March, June, and July of 2018. In March, 3 of 4 weeks were missing inspections. In June, 2 of 4 weeks were missing inspections. In July, 2 of 4 weeks were missing inspections.

These findings were reviewed with the Manager of Plant Operations and Director of Facilities Management at the time of record review.

Based on observation the nitrous oxide central supply room was not ventilated or protected with appropriate fire rated protection in accordance with NFPA 99.

Findings include:

On 3/12/19 at 11:30 AM during a building tour it was observed that the nitrous oxide supply room was not properly ventilated or fire rated.

1. There were louvers in the door and the wall above the door, compromising any fire resistance rating of the room. NFPA 99 section 5.1.3.3.2(4) requires central supply systems to be in a 1-hour fire rated room.

2. The room was not ventilated, other than the louvers in the wall and door, which opened to the corridor. NFPA 99 requires either natural ventilation to the outside or mechanical ventilation. Such ventilation must also be in accordance with the other criteria listed in section 9.3.7.5.

These findings were reviewed with the Manager of Plant Operations and Director of Facilities Management at the time of observation.